Encouraging public service improvement through shared learning and knowledge exchange

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Why is the Good Practice Exchange at the Wales Audit Office running seminars that focus on frequent users? Dyfrig Williams outlines our thinking and how services can provide efficient citizen-centred public services.

The Good Practice Exchange at the Wales Audit Office decide on our programme of events based on the following criteria:

New legislation and other significant developments affecting public service delivery

Legislation

If you’ve attended any of our recent seminars, you’ll have heard the Auditor General for Wales talking about how the Wellbeing of Future Generations Act is a gamechanger for Welsh public services. Organisations are required to integrate and collaborate; to think about prevention and the long term; and to involve people.

The Social Services and Wellbeing Act reinforces this by focusing on people, wellbeing, prevention, partnership and integration. The current public service environment clearly supports public service delivery that centres on citizens. If you’re looking to revamp your service to meet this focus, then these acts provide a framework and a rationale for change.

“The calls ranged from the routine to the extreme: from a caller that did not require any urgent treatment who had contacted the service for the third time that night to a patient suffering life-changing injuries as a result of a road traffic collision. I’m assured that the life of a paramedic is never dull…..

“Calling an ambulance is not always the right choice and other alternatives, such as pharmacies and out of hours services can get patients seen quicker and allow ambulances to respond to the cases where they’re most needed. It also taught me that the need for the public sector to work together to provide better services and to provide services for unmet needs and to fill service gaps is greater than ever.”

The Wales Audit Office’s Picture of Public Services report also paints a stark picture of the challenges that devolved public services’ face. The report shows that public services have faced significant and growing financial, demand and capacity pressures since the previous report in 2011. Some of the headline messages include that:

Organisations are in a position where they have to take well-managed risks to deliver sustainable solutions to financial and demand pressures on public services

there are difficult barriers to overcome in order to radically reshape services, including political and cultural barriers

‘What gets measured gets managed’ – public services are increasingly adopting ‘outcome’ measures, but there remains a tendency to measure and manage how much activity is going on and how long it takes

public services need to work together through the difficult choices to understand the short and long-term impacts for the public and other public services, and to mitigate those impacts where possible.

From a purely economic perspective, the case for change is clear. Public services will continue to waste valuable resources unless we work together, resources that could be better spent to provide services that people actually want.

Working with key stakeholders

Every event that we run is developed in conjunction with a range of stakeholders, and this is no different. We’ll have speakers from local authorities, health boards, the Ambulance Service, Fire Service and the Older People’s Commissioner. More than anything though, the event will look to share good practice from delegates’ own experiences and will throw out issues that people are facing to the collective expertise at the event.

We’ll also be ensuring that the focus of the event is firmly on what people want from their services. When I was tasked with working on this event, I immediately thought of a workshop that Simon Pickthall from Vanguard delivered at our Reshaping Services with the public event. In this seminar Simon shared how traditional public service interventions had failed to meet people’s needs because inefficiencies were resulting from maintaining broken organisational processes. These inefficiencies become obvious when we think about how public services work – people are made to fit into organisational silos, instead of organisations working together to meet people’s needs. Simon gives a really good overview of some of what he’ll be talking about at 6:37 in the below video.

The Stoke-on-Trent case study in the Picture of Public Services report (p.108) is an example of the approach that Simon will share. But we won’t be telling people what to do or directing people to use particular methods. We don’t believe that one size fits all – we need to look at the good work that organisations are doing and think about how we might adapt those approaches to suit the needs of people in our areas. And if we can do that, then we’ll be better placed to deliver the best possible services for the people of Wales.

I guess that writing about what you do is common practice in most professional arena, but normally it is for a very limited audience – the employer, sometimes even service users so that they can see what a professional worker is explaining what they saw, what they did and what they intend to do. Writing for an academic journal is a different piece of work – the audience is wider, the rules feel more complex and the writing comes under more scrutiny.

I have always experienced collaboration and/or integration as the natural way of building alliances to ensure that people are not ‘given the run-around’. Sadly my experience is that the public sector has provided that experience for ordinary people, leaving them with the energy-sapping task of finding their way around systems, places and people to try to find a response to a set of circumstances that is troubling them. So by simply reducing the number of doors to knock, telephone numbers to ring and people to talk to, the path becomes less hazardous, less tiring and more likely to lead to success for the ordinary person.

That becomes the rationale for collaboration and integration – to improve people’s lives and only that end makes it worthwhile.

The people who have contributed to the Wales edition had very little experience of writing for the purposes of publication. They had all written for their own agencies, arguing for a change in practice, arguing for an allocation of some additional resources and the many other reasons that we have to put pen to paper (or fingers to keyboard) for our employers.

It has been a struggle, everything took longer than anticipated and there was always another reference to call on. In many ways it reflects the struggle that is captured by many of the authors, to hold on to a belief that what they were pursuing was worth all the effort, to resist the feeling that ‘I don’t really have anything to say that people want to listen to’.

Their efforts, actually our efforts, since it started with us all talking about the idea in a room in a church centre in Shrewsbury – a good start since it reminded us that you sometimes have to break the rules to achieve something – (in this instance choosing to meet outside of Wales!!) were worth it.

The articles highlight the theme of the WAO events on 14th and 22nd October, that integration and collaboration are less about science and more about craft and graft, continually pushing at the boundaries of traditional thinking and reminding ourselves that there is never a reason not to ‘do the right thing’, but there are often many reasons to simply continue to ‘do things right’. The former is about people and the latter often about little more than adhering to process.

However the process was energising and in the end, successful. It shows the character and
strength of the best practice, the importance of leadership that is unrelentingly determined and the most critical of all, that a focus on what makes a difference to people’s lives pulls you through and beyond the doubters and the resistors!!

In August 2011 a joint report published by CSSIW and Estyn found that the Council failed to properly protect and safeguard children and young people in its education services.

At the same time and on a broader level, WAO had identified numerous failings in the corporate governance of the Council, failures were of such scale and significance that there was a risk the Council was failing to comply with its statutory duties. They noted “there has been a systemic corporate failure to respond sufficiently to safeguarding issues.”

In December 2012, Pembrokeshire County Council was placed in special measures following an Estyn inspection which found that both the Council’s education services for children and young people and its prospects for improvement were unsatisfactory.

Following the critical joint report in 2011 the authority began the process of change with the support and intervention of a Welsh Government appointed Ministerial Board. While some good progress was made it would be fair to say that this progress was often slow due to some deep-seated cultural and structural barriers to change. It was recognised that the pace of change was not sufficient given the level of challenges facing the authority.

In the summer of 2012 the authority appointed a new Director for Children and Schools and he was tasked with leading the change process and increasing the pace at which changes were made.

Central to this was merging the education service and the children’s social care service under one directorate and this measure was targeted at tackling historical issues which existed because the services responsible for delivering services to children and young people sat in different directorates with different ways of working (for example, the lack of integrated services or joined-up working was a major contributing factor to the authority’s safeguarding failings).

Following Estyn’s December 2012 report the authority moved rapidly to create the momentum needed for radical change. Some of these interventions are highlighted below:

The Director made difficult and sensitive decisions to rebuild and refresh his leadership team and began the process of establishing an entirely new senior management structure across the merged directorate by making external appointments to key posts and removing existing barriers to change.

The authority developed collaborative arrangements with Carmarthenshire by agreeing to merge school improvement services through an extension of existing regional working arrangements. This included a joint appointment of a Head of School Effectiveness to lead the school Improvement service across both authorities. The shared arrangements have created mutual benefits for both authorities creating critical mass and greater capacity across the region.

The Director has led the development and roll-out corporately of a cross-cutting quality assurance framework for safeguarding that encompasses schools, children’s services and human resources.

A representative head-teachers group has been developed (originally established by the ministerial board) to influence and test the ongoing impact of change and to be a catalyst within the authority to improve peer challenge and build schools own capacity.

The operation of overview and scrutiny committees was overhauled and a key joint Committee across Safeguarding and Children & Families focussed on the Estyn Inspection report and demonstrated public acceptance of the challenges faced.

Underpinning the change programme was the Pembrokeshire Post-Inspection Action Plan (PIAP) which the authority was required to produce and implement in response to the 7 recommendations made by Estyn in its report.

The development of the PIAP was led by the Director with the engagement of a broad cross section of elected Members, governors and schools and the positive contribution made by the wide range of stakeholders in the development of the Plan has resulted in a common vision and clear shared sense of purpose, building consensus for fundamental change.

The PIAP is a comprehensive plan that reflects the significant shortfalls in performance identified by Estyn and became the overarching framework for change not only across education and children’s services but also at a broader corporate level and the county as a whole.

Following the highly critical reports received in 2011 Pembrokeshire instigated a programme of rapid improvement and change under the strong leadership of the Director of Children’s Services. Significant improvements were made in a number of key areas and Pembrokeshire is now leading the way sharing the best practice it has developed with other Local Authorities.

Pembrokeshire is now out of special measures in making that decision, Estyn said that following the 2012 inspection, the Council had acted ‘quickly and decisively’ to plan for change which resulted in significant improvement. The Estyn report continues: ‘The Chief Executive, Leader and senior officers took difficult and sensitive decisions to remove barriers to progress in order to bring about the necessary improvement.’

In response to the good news the leader noted ‘The result is a more dynamic, transparent and outward-looking local Authority. This is just not my opinion but is also the view shared by the inspectors.’

‘We remain committed to doing everything that can reasonably be expected to keep children in our County safe. Today’s decision by the inspectors formally acknowledges that they have confidence in our services.’

In 2011/12 Estyn and CSSIW inspections identified the need for Pembrokeshire County Council to address problems in the retention and recruitment of social workers. Below, Anne Nicholson tells us how they’ve gone about doing just that.

We undertook a significant piece of research on recruitment and retention, workloads and support for social workers. We discovered from that research that we have a high number of social workers who appreciate living and working in Pembrokeshire and who want to continue to work for the Authority. This is of course a strength, however they reported that the benefits of living and working in the county did not counter the argument for the “going rate for the job” and the need for manageable caseloads. We had a high number of experienced practitioners with appropriate skills who were committed to working with children, young people and their families.

The safeguarding Overview and Scrutiny committee identified the recruitment and retention of social workers as a priority for Pembrokeshire made it a standing item on their agenda, receiving regular reports on progress with this work.

The Social Care Workforce planning project was selected as one of Pembrokeshire’s Outcome Agreements for 2013-2016. As well as being a priority for Pembrokeshire County Council, it demonstrated a clear link to the Wales Programme for Government’s Strategic Theme of Tackling Poverty. We believed that by providing an effective professional social care service with a sufficiently qualified and trained social care workforce, the outcomes for children, young people and families living in poverty would be improved. We set out to achieve this through:

The development of a model for the recruitment and retention of social workers

The development of effective mechanisms for referral to the Flying Start project for children & families to receive specialist support.

Together, the pay and grading review and the development of technologies to aid recruitment have proved successful in leading to improvements in this area. The market supplement and results of the Pay and Grading Review produced an increase in the ranking of starting and top of scale salaries in Pembrokeshire and have positioned Pembrokeshire more competitively. The number of vacant social worker posts reduced by 88%; the number of required agency staff reduced by 60% and the overall turnover rate has reduced.

We have reduced costs by moving away from the more traditional, and often more expensive, methods of advertising (which is part of our overall Social Work recruitment strategy) and successfully recruited candidates via new methods of advertising e.g. via YouTube, Google, Facebook and LinkedIn.

We now have a robust procedure for the employment of agency workers and there must be a vacancy in a team before they are employed.

David is Consultant Physician, Royal Berkshire NHS Foundation Trust; Visiting Professor of Medicine for Older People, City University, London; Visiting Fellow, the Kings Fund; President-elect, British Geriatrics Society; and Recently of the Department of Health National Clinical Director for Older Peoples Services (England).

Population ageing is surely a cause for celebration not catastrophising. It represents a victory for societal conditions, for preventative medicine and public health and for advances in medical treatment. And it gives all of us a higher chance to live well in to older age. Just after the Second World War, nearly half the UK population died before 65. It’s now only 14%, with the over 80s the fastest growing demographic. By 2030 a UK man of 65 will live on average to 88 and a woman till 91.

Although older people generally report high levels of wellbeing and happiness and many remain remarkably independent and connected, we can’t duck the fact that more older people has inevitable consequences: more people with multiple Long-Term Conditions, with frailty syndrome, with Dementia and with a degree of disability or dependence. These same individuals are often reliant on multiple services and practitioners and on informal care from family and friends.

Our current service model needs to shift far more towards prevention, towards co-ordinated care focussed around the needs of individuals rather than single disease and to recognise that the care of such older people is now “core business” for health and care systems. If we don’t get care right for older people with complex needs, we won’t get it right for any group. This has radical implications for workforce, education and training and for collaborative and integrated working between organisations. Wales already has some of the building blocks in place to help realise these goals and many current examples of good services for older people. But we need to spread and implement good practice at scale and pace to get “the rest as good as the best” and be prepared to look to other health systems for other examples of “what good looks like”.

We hope these events and the “community of good practice” which follow on from them will help facilitate the public conversation, improve collaboration and encourage the dissemination of good ideas. Ultimately, we hope it will result in services that go beyond “mission statements” and really are built around the needs of our ageing population.

Here is a snapshot of the key messages from a recent report by Professor Oliver and his colleagues, ‘Making our health and care systems fit for an ageing population’.

Richard is an 88 year old man living alone at home. One Friday afternoon, his neighbour becomes worried about his condition, and calls the local surgery. The GP visits before evening clinic and quickly realizes that Richard has an infection which needs immediate treatment. It is perfectly feasible to treat him at home, but Richard is going to need nursing input, and some other care at home over the weekend to ensure that he is properly looked after. If the GP can arrange this quickly, Richard can stay at home. Is that package of care immediately available, or will Richard have to be admitted to hospital, with the very real risk that his capacity for independent living will never recover?

Eileen has a terminal condition, but since it is temporarily under control, she is about to be discharged from hospital. Her daughter is phoned by the social worker to tell her that Eileen is about to come home to the daughter’s house, since that was where he was admitted from. ‘But I can’t provide the level of support she now needs, I’m out at work all day’, she tells the social worker. ‘Anyway, why wasn’t this thought about when she was first admitted?’ ‘Well, we are where we are. We will have to declare your mum homeless, and then ask Housing to assess her needs.’ ‘But that’s going to take days… Can’t you sort something out directly with your Housing colleagues?’ ‘Oh no, not unless she’s actually homeless’. Is Eileen going to spend precious days waiting on the ward for the system to work for her?

Care and support services are fundamentally about meeting the needs of individuals yet the government agencies which organise and deliver those services are big bureaucracies whose focus often seems to be on a mixture of politics, budgets, systems and strategies. So, how can we ensure that the individual, who by definition is at a vulnerable point in life, remains the primary attention of commissioners and providers, with the bureaucracy becoming at most an invisible backcloth?

The ‘Strengthening the Connections‘ initiative has been designed to bring colleagues in the public, voluntary and independent sectors closer together in ensuring people receive services without feeling the lumps and bumps of being transferred from one to the other. Lessons learned elsewhere suggest leaders and managers must resist the temptation to concentrate their integration efforts on structures and organisational change and, instead, prioritise the care needed by service users, carers and patients at the individual level. Of course, changes in systems and processes will be critical to making the necessary changes but only if they are made on behalf of the individual.

WIHSC – the Welsh Institute for Health and Social Care – is pleased to be supporting ADSS Cymru and the Welsh NHS Confederation, and their partners, with their ‘Strengthening the Connections’ project through the organisation of four major regional demonstration events across Wales. These will bring together a range of people from across health, social care and the voluntary and independent sectors to hear about successful initiatives in integrating services and to discuss how progress can be made on a regional and national basis.

WIHSC will also be working closely with key leaders and managers in the seven Welsh health and social care communities to assist in finding ways of moving the integration agenda forward. These ‘strategic conversations’ will help identify the enablers and barriers to progress and identify the key actions needed.

Integration has shot up the buzz word charts recently. If it’s to make a difference to the care and support people receive, the familiar tune of “To You, To Me” must change.

So why so much attention on integrating services, particularly health and social services? Well it makes sense if the public sector is to move away from, sadly, what it has been very good at, for as long as I can remember and as long as I have been a part of it – so this is not written by a paragon of virtue!!

It is ‘giving people the run-around’

Ask anyone who is a regular user of both health and social services and they will be able to describe circumstances when they have been passed back and forth between agencies and professionals, often left to sort out the distinction between different agencies’ processes and their differing responsibilities, without help and support.

When to go to the council, when to the NHS, when to a voluntary organisation? And what are the consequences if you get it wrong? At best it can mean a delay and at worst, not having access to the right information and advice to help find a solution or response to what is troubling you.

So that is the reason that integration and collaboration between agencies is so important. It makes it easier for people to negotiate their way around the system, or usually the SYSTEMS. Seldom will it feel like one system.

‘Strengthening the Connections’ is trying to bridge the gap that people experience between NHS and local government, whilst recognising that there are also many other agencies involved in offering support to people when they need help, so there need to be easy links between and good relationships across all agencies. People do not live their lives in the boundaries of agencies’ responsibilities, so professional workers and agencies should be making it easy for someone to negotiate their way to gain support, not leave people stranded in what often feels like a very complicated system. Association of Directors of Social Services Cymru and Welsh NHS confederation are working together on this project to make this happen, showing that it is possible to overcome differences, if we focus on our common aim, to improve the services available for people and their experiences of those services.

Welsh Government paid for this project as part of supporting the implementation of a very important piece of legislation currently making its way through National Assembly of Wales committees, the Social Services and Well-Being (Wales) Bill. The Bill makes an absolute priority of improving people’s lives, giving people control over their lives and removing unnecessary and unhelpful barriers for people to receive decent services

There are some important and common messages emerging from our work that will lead to real improvements:

Listen to what people tell you about what works and what doesn’t – do more of what works and less of what doesn’t.

Develop an understanding of the business of other agencies – this will stop you simply passing the buck to others and invite you to help people negotiate their way towards a decent service.

If you are doing something on your own, you are probably doing it wrong – as a front-line worker, look out for the other workers who are involved in the person’s life and make contact with them; as a manager, meet and talk with managers from other agencies and explore what you can do together – discover the joy of sharing responsibility!

Be prepared to let go of being in control of what happens – other people may have something helpful to offer and it is often the person who needs support, when given a voice, who can provide the clue to what will make a difference to their life

Strengthening the Connections means just that: we have to find ways to bring services together so that we build what we have to offer around people lives, rather than expecting people to fit into the boundaries that we have artificially created around professional behaviour and agency responsibilities.

However it is not easy, as we have to let go of how we have done things in the past and we have to allow others to influence what we do, but…..

Doing it differently is also much more fun, more challenging and calls on more creativity, as we find ways to move forward together and with the public that we serve.

Like this:

Recently we’ve been hearing from the Wales Audit Office Communications Team about how our upcoming new and improved website will be simpler to use and also make it easier for people to find the information that they need.

Andrew Purnell, the Wales Audit Office’s Digital Communications Officer, has been educating us as a team about what an effective website looks like, and also how language plays an important part in that. It’s almost impossible to find what you’re looking for if you don’t understand the headings you’re looking under, and it’s even worse if you can’t make head nor tail of the information once you’ve got there. He explained to us how providing a website glossary means that you’ve failed at your duty to provide a clear language website, and if people don’t find the right information first time they’ll simply click away from your site.

As the public service watchdog for Wales, the Wales Audit Office has an important role to play here. It’s important that we show how important it is that information from Welsh public services is clear, because it means that people have a better understanding of the work that we all do.

Cllr Andrew Jenkins recently blogged for us ahead of the upcoming scrutiny conference, saying that ineffective communication between politicians and the electorate has led to distrust in politicians. The same things can also happen with public services, as this moving blog from Mark Neary shows.

I had the privilege of working with the Citizen’s Panel for Social Services in Wales in my last job with Participation Cymru, where I unfortunately heard too often about how people aren’t given the information they need to help them access the right services for them. It’s important that we all make sure that people can make the most of their public services by making information both easy to find and to understand. I wonder how many public service websites truly do this?